Bundle Implementation: The Importance of Leaders in Change
Tom Ahrens, DNS, RN
Research Scientist
Barnes-Jewish Hospital
St. Louis, Missouri, USA
Suzanne Golden, BSN
Nurse Manager
Memorial Hospital
Colorado Springs, Colorado, USA
During the past several years, the term bundles has been introduced into standard critical care practice. As one of the leaders in bundle development and implementation, the Institute for Healthcare Improvement (IHI) defines a bundle as “a structured way of improving the processes of care and patient outcomes: a small, straightforward set of practices - generally three to five - that, when performed collectively and reliably, have been proven to improve patient outcomes.” All hospitals are expected to use concepts like bundles to help refine organizational processes to improve outcomes.
The use of bundles has been instrumental in improving patient care, primarily by using evidence-based practice guidelines as the backbone for clinical practice, and in reducing resource utilization. Bundles have become so successful that their use could be considered a standard of care.
The clarity of bundles and guidelines has contributed greatly to their widespread and successful use. However, in many organizations, it is still difficult to overcome institutional and personal barriers that limit successful implementation. A few key leaders, or champions, are the key to overcoming these barriers. These leaders are often volunteers, because hospital organizational structures do not have formal positions for such personnel. Subsequently, each hospital may have different clinical and administrative leaders. An intensivist may be the physician leader in one hospital; in other institutions, the role may be filled by a pulmonologist, anesthesiologist or surgeon. Nurse leaders may be managers, directors, advance practice nurses or educators.
A single key leader usually is not enough to ensure bundle implementation. Physicians, administrators and other team members also are essential to success. However, nurses often take on the role of a bundle champion in collaboration with other clinical and administrative leaders. A nurse usually takes charge of the day-to-day leadership to ensure all components of the bundle are initiated properly; this is considered one of the most critical roles in bundle implementation. Nurse leaders often ensure that consistent methods for patient identification are used and that outcomes are evaluated routinely. Nurse champions are often in a unique position to work with various professionals in different departments; for example, they have access to physicians and laboratory and administrative professionals.
For a bundle to be implemented effectively, nurse champions must have the support of other institutional leaders, particularly physicians and administrators. In cases of limited authority and accountability, bundle implementation likely will not achieve its full impact or change clinical practice.
It may be worthwhile to attempt bundle implementation even when ideal conditions are not present. Although implementing bundles without full organizational support clearly is not desirable, taking no action is unacceptable. In many organizations, only two or three individuals may be willing to take on the role of bundle champion. As long as it is understood that the effects of implementation may be limited, a few key leaders can attempt it. Improvement in patient outcome and reduced costs can be demonstrated when as few as two clinical leaders put substantial personal effort into bundle implementation.
The Work of Few Affects Many
At Memorial Hospital in Colorado Springs, Colorado, USA, three key clinicians, the nurse manager, intensive care unit (ICU) nurse clinician and the medical director, guided a program that addressed key aspects in the IHI’s 100,000 Lives Campaign. These clinicians targeted three key clinical areas that they felt would have the most significant effect on patient outcomes and length of stay. The change champions focus on:
• Improved ventilator management: implementing daily spontaneous breathing trials and the ventilator-associated pneumonia bundles
• Early sepsis identification: daily rounding to identify patients who meet sepsis criteria and implementation of the severe sepsis order set
• Early communication about high-risk patients: daily rounding to identify these patients on admission to ICU and consistent, daily communication with patients and families regarding care and expectations
Within 12 months of beginning this effort, these clinicians established multiprofessional rounds and began to see the positive results.
• Ventilator days decreased from 6.43 days to 5.18 days
• The ICU went nine months without a case of ventilator-associated pneumonia
• Length of stay decreased from 7.52 days to 6.12 days
While this effort improved patient outcomes, it also resulted in cost savings of more than $1 million. Seeing the importance of this effort, this group even went further, aiding in the formation of a statewide collaborative in Colorado to work with the Surviving Sepsis Campaign.
While many clinicians and members of the team aided these three champions, this example points to how the leadership of a few can act as a positive catalyst for change. Many hospitals have shown that successful bundle implementation improves patient outcome and reduces resource utilization. Overcoming organizational and individual barriers is the challenge for hospital clinical and administrative leaders, but the benefits of successful bundle implementation are well worth the efforts required.
